Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX C n Trauma Care in Mass-Casualty, Austere, and Operational Environments
injured, some may survive and some may not. Triage is
a dynamic process and must be repeated with greater
focus and discrimination as casualties move away from
the scene to other settings and healthcare facilities.
Each casualty category should have a defined area
for collection and management. Immediate casualties
should gain entrance to the emergency room. Delayed
casualties can be initially managed in outpatient clinic–
type settings. Minimal casualties can be kept outside
of hospital main treatment areas in adjacent buildings.
Expectant patients must have their own area. Although
not expected to survive, these patients should not be
labeled as dead, since resources and situations may
improve and allow for later attempts at salvage without
harm to other patients.
Management Priorities
The ATLS primary survey provides the framework
for initial casualty assessment and intervention by
receiving providers. Simple clinical assessments
and interventions are paramount in austere and
operational environments. Creative solutions involve
improvisation of materials to address life-threatening
physiology. For example, an initial airway intervention
might stop at side positioning and placing an oral
airway in an unconscious patient when endotracheal
tubes and the resources to manage the casualty after
intubation are not available. Surgical airways might be
considered, using tubes that are readily available, such
as a hollow pen casing. Restriction of cervical spine
motion can be accomplished with rolled blankets or
the patient/casualty’s shoes. Supplemental oxygen
is likely to be unavailable. Absent stethoscopes
and sphygmomanometers, assessment for tension
pneumothorax might be performed with ear to chest
and blood pressure estimated with a pulse check
(carotid 60 torr; femoral 70 torr; radial 80 torr). Needle
decompression requires longer needles in muscular or
obese individuals. Field chest tubes can be managed
with a “Heimlich valve,” constructed as the cut finger
of a rubber glove over a tube.
Circulation is addressed by stopping the bleeding.
Commercial tourniquets are a useful investment for
hospital and emergency medical services (EMS) disaster
supplies. Although somewhat less effective than
commercial devices, tourniquets may also be fashioned
from belts, clothing, or cables and used to manage
bleeding from mangled or amputated extremities. This
frees the hands of responders to manage additional
casualties. Vascular access and volume are secondary
considerations to rapid cessation of bleeding. In
conscious casualties, oral fluids might be appropriate
for management of hypovolemia. Scalp lacerations
can be managed with rapid whipstitch closure. Longbone
extremity fractures can be reduced and splinted
with improvised materials to reduce hemorrhage and
limit pain.
Typical trauma patient care moves quickly from
primary survey with resuscitation to secondary survey
and definitive care. However, providers may need to
defer the secondary survey and definitive care in favor
of identifying and managing as many casualties as
possible with life-threatening injuries. That is, the
secondary survey and definitive care may be delayed
from the primary survey and resuscitation. Beyond the
focused assessment with sonography for trauma (FAST)
exam, there is little role for extensive radiological
imaging and laboratory studies in the first phases of
mass-casualty response—a single radiology tech and
x-ray machine can perform conventional trauma x-ray
studies on only about six patients per hour.
Challenges
Communication is the dominant challenge in
disaster response across all environments. Normal
communication systems are often nonfunctional, and
multiple agencies and organizations, each with its
own procedures and taxonomies, are brought together
under stress with equipment and protocols having
limited interoperability. Even the trauma team itself
may be comprised of members who do not normally
work together. Application of the National Incident
Management System’s - Incident Command System
(ICS)can improve response and communication.
Communication plans should be rehearsed regularly
with disaster exercises. Good communication will also
provide valuable information about outside events,
available plans, and resources, thus reducing fear
and rumors.
Transportation options are often limited; any vehicle
can be used to move casualties, including buses,
cars, and boats. Safety and security are challenged
due to environmental and conflict conditions. These
conditions should be emphasized, planned for, and
practiced in drills. Protection of the facility is a key
function of the operations chief in ICS. Logistics is
challenged by the just-in-time supply systems of
many hospitals, and this function can be facilitated
by regional mutual supply caches and prearranged
supply orders. State and federal government agencies
can supply resources; however, delays of 96 hours or
more before full mobilization have been experienced
in past incidents.
Mass volunteerism and self-deployment can swamp a
facility or scene with well-meaning providers who have
undetermined credentialing and skills. They must be
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